Understanding Chest Pain: MI Symptoms & Treatments

1. Chest Pain/ MI/Shock Victor Politi, M.D., FACP Medical Director SVCMC PA program

2. Approximately 1 million hospitalized patients each year have MI as a principal diagnosis • Approximately 200,000 - 300,000 people in US die from MI’s each year

4. MI Risk Factors • Smoking • HTN • High fat diet • High LDL • Diabetes • Stress • Inactivity • Male gender • Age/Heredity • Elevated homocysteine and C-reactive protein levels

5. A patient presents with chest pain • What do you do?

8. Stable angina, unstable angina, ACI, AMI • An indistinguishable spectrum • beginning with stable lumen-restricting coronary artery plaques • results in plaque fissuring • initiates platelet adhesion & fibrin plugs w/overlying but non-occlusive thrombus • results in plaque disruption, occlusive thrombus composed of fibrin, platelets & erythrocytes

9. Most heart attacks are caused by the build up of atherosclerotic plaque inside the arterial wall - which can trigger the formation of a thrombus

10. Frequency of “Silent” AMIs • Framingham Study: largest long term prospective study of cardiovascular disease • Cohort of 5,127 participants • 708 (13%) suffered AMI • 213 (30%) were not recognized during AMI • Only 1/2 demonstrated classic AMI S/Sxs allowing identification of AMI in retrospect

11. Classic Presentation • Retrosternal, epigastric chest pain or tightness • SOB • Diaphoresis • Nausea, vomiting • Levine’s sign

12. Atypical Symptoms of AMI • Admits chest discomfort- denies pain • A little sweating previously - now gone • Previous indigestion - now ok • May or may not have mild SOB • Can’t describe symptoms - uses vague terms • EKG normal or non-specific changes present • In fact - an atypical presentation is the most typical presentation

13. Symptoms - pain • Chest pain- • typically below the sternum • intense/severe/subtle • squeezing sensation/heavy pressure • Angina not relieved by rest or nitroglycerin • Back pain • Abdominal pain • Pain radiating to • shoulder/arms/chest • neck/teeth/jaw • back • Pain that is prolonged > 20 min

14. Other Symptoms • Bad Indigestion • Dyspnea • Cough • Syncope • Nausea or vomiting • Diaphoresis • Anxiety

15. Physical Exam • Rapid pulse • BP - varies • may reveal abnormal chest sounds on auscultation • Diaphoresis

16. Studies • ECG • Echocardiography • Coronary angiography • Stress test • EST • Nuclear • Studies which show heart damage or high risk • Troponin I / troponin T • CK and CK-MB • Myoglobin-serum

17. Additional Lab Tests • CBC • 6 • Pt/Ptt • Chest x-ray

18. What is first in your work-up? • 12 lead ECG • Is it useful ?

19. A “normal” ECG • Studies show that as many as 15% of ECGs are completely normal and 60% of ECGs are normal or show nonspecific changes even in the presence of an evolving AMI • When are ECGs useful ?

20. Treatment • Continuous ECG • Continuous BP • IV - fluids/meds • oxygen • Pulse ox • Blood work • urinary catheter - to monitor fluid status

21. ASA

22. Aspirin • 40% relative reduction in mortality • What’s the right dose? • Probably the single most important thing we can do • Irreversible - inhibit platelet aggregation

23. Aspirin -Contraindications • ASA Allergy • GI bleed • Bleeding disorder

24. Nitrates • When should nitrates be given? • Who should receive nitrates? • Who should not receive nitrates? • Dose • SL NTG • Spray • Paste • IV

25. Morphine MSO4 • Does morphine reduce pain? Yes • Does morphine reduce mortality/morbidity? NO • Morphine vs NTG

26. Glycoprotein IIB/IIA Inhibitors • Utilized in ACISs without AMI • Action is to “de-couple” platelets • Three FDA-approved • Integrillin - eptifibatide • Aggrestat - tirobifan hydrochloride • Repro-abciximab

27. Heparin • When should heparin be given? • Who should receive heparin? • What is the right way to give heparin? • Is there a wrong way to give heparin? • Other forms of heparin, anticoagulants? • Therapeutic monitoring • Oral anticoagulation - • Warfarin • Coumadin

28. Low-molecular weight heparin • Enoxaparin dosed 1mg/kg SQ Q 12 hr • No PTT monitoring necessary • potential of fewer labs drawn, run • No IV necessary • fewer IV starts, no pumps, outpatient treatment • Fragmin

29. The ESSENCE Trial • Efficacy & safety of SQ Enoxaparin in non-Q-wave coronary events • Significant relative risk reductions (RRR) & cost savings compared to unfractionated heparin • >15% relative risk reduction in incidence of death, AMI, recurrent angina & combined triple endpoints • 10% relative risk reduction in CABG • 21% relative risk reduction in PTCA • Decreased resource utilization resulting in cost savings exceeding $1000 per patient

30. Beta-blocker IVP • When should beta blockers be given? • Who should receive beta blockers? • Who should not receive beta blockers? • What is the right dosing regimen? • Primary, secondary benefits? • B1-B2 Blocker

31. Ace Inhibitors • Studies show decreased mortality if given in first few days after AMI • Benefit due to effects on myocardium remodeling • long term benefits show increased EF and decreased incidence of CHF

32. Cholesterol Lowering Agents • Current thinking; the lower the total and LDL cholesterol - the better ! • Many types available -currently the statins seem to show the best reduction

33. Thrombolysis: Eligibility Criteria • No age limit • Clinical • Chest pain, chest pain-equivalent c/w AMI of < 12 hrs from onset or < 24hrs if “stuttering” • EKG • 1mm or > ST elevation in 2 or + limb leads • 2mm or > ST elevation in 2 or + precordial leads • New onset bundle branch block

34. Contraindications to Thrombolytics • History of CVA/TIA within 6 months • Recent head trauma, known intercranial mass • Surgery, PTCA, severe trauma in past 2 weeks • Recent GI bleed or ulcer • Persistent, uncontrollable SBP >200, DBP>110 • Non-compressible venous or arterial puncture • CPR greater than 10 minutes • Aortic dissection Dx=> CT of thorax • Pericarditis

35. Thrombolytics • TPA • Retavase • Streptokinase • Door -to-Drug Time • Time is Muscle!

36. Goal of Treatment • Stabilize patient • Stop the progression of heart attack - • prevent further heart damage • Reduce demands on heart • so it can heal • Prevent complications

37. Other cardiac conditions

39. Bradycardia • Systolic rate < 60 • Symptomatic • Atropine • Isopril • Pacemaker • What medications has the patient taken?

40. Atrial Arrythmia • A Fib • A flutter • SVT • PAT • PAC

42. Atrial Flutter

43. AV Blocks • 1st degree AVB • 2nd degree AVB • Type 1 • Type 2 • 3rd degree AVB

45. Ventricular Arrythmias • PVC • V Tach • V Fib • Torsades • Ventricular escape beat

46. An 84 year old lady with hypertension--First degree AV block

47. Cardiogenic Shock • Symptomatic blood pressure <90 systolic • due to low cardiac output • Goal of treatment - increase perfusion to vital organs • Treatment options include Dopamine/Dobutamine/Levophed/ balloon pump (aortic counterpulsation)

48. Cardiac Tamponade • Hypotension caused by reduction of cardiac output secondary to inability of the ventricle to provide adequate stroke volume due to fluid in the pericardial sac